Matomo

Medical Waiver | Northgate
Authorization for Medical Treatment of Minor

My child is attending and participating in activities hosted by Northgate Christian Fellowship of Benicia (hereinafter "church”) located at 2201 Lake Herman Rd., in the City of Benicia, County of Solano, and State of California, during the 2023-2024 Calendar Year beginning on the day of July 1, 2023, through June 30, 2024

I hereby authorize the Pastors, Staff, and his/her officers, agents, servants, or employees that are 18 years of age or older, who supervise the activities by this Church into whose care my child has been entrusted, to consent to medical care or dental care, or both, for my child under Sections 6901, 6902, and 6910 of the California Family Code.

The authority granted by this authorization includes the authority to consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician and surgeon licensed under the Medical Practice Act for my child. This authority also extends to any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment and hospital care by a dentist licensed under the Dental Practice Act for my child.

I further authorize the Pastors, Staff, and his/her officers, employees that are 18 years of age or older, who supervise agents, servants, or the activities by this Church to receive physical custody of my child, under Section 1283 (a) of the California Health and Safety Code, upon completion of any treatment, and I specifically instruct any treating health facility to surrender physical custody of my child to Pastors, Staff and his/her officers, agents, servants, or employees that are 18 years of age or older who supervise the activities at this Church. It is understood that this authorization is given in advance of any special diagnosis, treatment, or hospital care being required but is given to provide authority and power on the part of the supervisor or his/her authorized designee in the exercise of his/her best judgment, upon the advice of such physician, dentist, and surgeon, may deem advisable.

I have read the Acknowledgment of Risks, Assumption of Risks and Responsibilities, and Release of Liability.
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Northgate is a non-denominational church located in beautiful Benicia, CA. Our staff and volunteers can't wait to meet and pray with you.

2201 Lake Herman Road
Benicia, CA 94510
(707) 747-5855
office@ngate.org
https://thisis.church


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Page Last Updated: May 28, 2024 at 1:39 PM